Name__________________________________________

Address:________________________________________

City___________________ State________ Zip Code_________

Telephone_________________________________

Email_______________________@________________

Age________

Family Income (Confidential)__________________________

Health Conditions if any (Confidential)________________________________________

____________________________________________________________

Any previous training please list:__________________________________________________________________________

_____________________________________________________________________________

I hereby make application to participate in the ZIAD Martial Arts Assistance program. I have reviewed this exercise program with my physician prior to starting the program. I understand I will be referred to a sliding scale program with a local program.

I release all persons, instructors, facilities, including ZIAD Healthcare for the Underserved Inc from any and all liability for any injuries I may sustain while participating in these programs. If I am under 18 years old my parent has signed below and agrees to the same.

I understand the program is based on a sliding scale program based on the family income.

.A FACIMILE SIGNATURE WILL BE CONSIDERED THE SAME AS AN ORIGINAL.

Signature__________________________________________ Date______________

Signature (Parent if under 18 yrs old)__________________________________ Date_________

Please Fax completed form to: 989-672-2483 or e-mail to ibrahamahmed@aol.com

or mail to: ZIAD Healthcare